1. Field of the Invention
The present invention relates generally to rhinitis treatment regimens. Particularly, the present invention relates to treatment regimens for rhinitis with rhinorrhea.
2. Description of the Prior Art
Rhinitis refers to an inflammatory disorder of the nasal passages. The symptoms of rhinitis typically consist of sneezing, nasal congestion, rhinorrhea and increased nasal secretions. Rhinitis may be allergic in nature, for example, hay fever occurring seasonally and due to airborne inhalants such as pollens, or non-allergic as in individuals who “appear to be allergic” but prove not to have allergic sensitivities. Individuals with non-allergic or “vasomotor” rhinitis often have persistent and even severe daily symptoms. Rhinitis may also be due to infections, for example as with common colds. Rhinorrhea (runny nose) and excessive secretions that occur with rhinitis are some of the most troublesome symptoms for patients. The act of constantly blowing the nose or wiping away secretions, or coughing consequent to post-nasal drip (secretions running down the back of the nose and into the throat) may, especially for adults, interfere with work or social interaction. Rhinorrhea and postnasal drip are considered challenging and often intractable symptoms for practitioners to effectively treat.
Two types of oral medication are commonly used to treat rhinitis: decongestants and antihistamines. Decongestants commonly used to treat rhinitis include the adrenaline-like agents such as pseudoephedrine. These agents act to constrict vessels in the nasal mucus membranes and thereby decrease tissue swelling and nasal congestion. Although their vasoconstrictor effects result in “opening” of the airways, decongestants do not have a drying effect so as to dry secretions.
Histamine is a mediator released from cells that line the walls of the nasal mucous membranes (mast cells). When released, histamine is known to bind to local receptors and thereby cause sneezing, nasal itching, swelling of the nasal membranes, and increased nasal secretions. Antihistamines block the binding of histamine to histamine-receptors in the nasal membranes. Antihistamines are effective only if given prior to histamine release (once histamine is released and binds to the receptor, it is too late). Although individuals typically take antihistamines after symptoms occur, it is more desirable to dose antihistamine so as to effect therapeutic activity in anticipation of the peak times of histamine release. Individuals with allergic rhinitis commonly experience peak symptoms in the morning hours on awakening, a time concomitant with peak histamine release and coinciding with peak exposure to airborne allergens that stimulate histamine release in sensitive individuals.
The first pharmaceutical entities recognized to have antihistaminic action, now referred to as first-generation antihistamines, have lipophilic chemical properties, which contribute to both a sedating and an anticholinergic, drying effect. Examples of sedating antihistamines are brompheniramine, chlorpheniramine, diphenhydramine, promethazine, and hydroxyzine. The sedating side effects of these antihistamines stimulated the development and marketing of non-sedating, or second-generation, antihistamines. While the newly developed antihistamines are less lipophilic than first-generation antihistamines (conferring a reduction in their ability to cross the blood-brain barrier and thereby cause sedation), second-generation antihistamines have a concomitant diminution of anticholinergic effects and decreased potency for drying secretions and controlling rhinorrhea. Examples of second-generation antihistamines are: loratidine (marketed as Claritin®), fexofenadine (marketed as Allegra®), and cetirizine (marketed as Zyrtec®).
U.S. Pat. No. 6,086,914 of Weinstein et al. teaches formulations for allergic rhinitis which combine such newer non-sedating antihistamines together with a third type of agent, an anticholinergic agent, to result in a dosage unit that is non-sedating and also has a drying effect upon the nasal membranes.
Anticholinergic agents, the third and less commonly used oral entity to treat rhinitis, are exemplified by the belladonna alkaloids atropine and scopolamine, which inhibit the muscarinic action of acetylcholine on structures innervated by postganglionic cholinergic nerves. These agents inhibit the nasal secretory mechanism and cause drying of the nasal membranes. Anticholinergic agents also are known to exert central effects that include papillary dilatation and stimulation and depression of the CNS. Drowsiness is known to occur with high doses of anticholinergic agents, and with therapeutic doses of oral scopolamine, but drowsiness is considered rare with therapeutic doses of other oral anticholinergic agents (USPDI Drug Information for the Health Care Professional, 16th Edition, United States Pharmacopoeia Convention, Inc., 219-235, 1996 Rand McNally, Taunton, Mass.). Anticholinergic pharmaceuticals have been developed which have a limited capacity to pass across lipid membranes, such as the blood-brain barrier, and therefore have a limited capacity to produce central effects, examples being the quaternary ammonium compounds methscopolamine and glycopyrrolate.
As with all medications, anticholinergic medications have side effects. Consequences of excessive drying of the mucous membranes include overly dry mouth and dry or sore throat. Decreased perspiration due to drying of the skin can lead to temperature dysregulation. Eye effects include dilitation of the pupils with photophobia, loss of accommodation, blurred vision, and/or increased intraocular pressure, a particular concern for people with narrow-angle glaucoma. Systemic side effects include potential for increased heart rate, urinary retention, constipation, and gastrointestinal ileus. Dosing with these medications therefore requires judicious attention to achieve benefit and minimize risks and side effects.
A number of individual medications containing an oral anticholinergic agent have been marketed for treating the symptoms of allergic rhinitis. Examples of these are:                1. Hista-Vent® DA Exended Release Tablets, which contains: phenylephrine 20 mg; chlorpheniramine 8 mg; and methscopolamine nitrate 2.5 mg.        2. Atrohist® Plus, which contains: phenylepherine hydrochloride 25 mg, phenylepherine 50 mg, chlorpheniramine 8 mg, and hyoscyamine sulfate 0.19 mg; atropine sulfate 0.04 mg, and scopolamine hydrobromide 0.01 mg.        
AlleRx® Dose Pack is a packaged rhinitis treatment regimen that contains a morning dosage that has 120 mg pseudoephedrine HCl and 2.5 mg of the non-sedating anticholinergic agent methscopolamine nitrate, and a nighttime dose containing the sedating antihistamine 8 mg chlorpheniramine maleate and 2.5 mg methscopolamine nitrate. It is licensed under U.S. Pat. No. 6,270,796 of Weinstein that teaches limitation of dosing of decongestant to the daytime hours to avoid excessive stimulation and nighttime insomnia. Notably, the AlleRx regimen utilizes anticholinergic agent both day and night and would result in the same anticholinergic dosing that would occur with a single dosage unit that was formulated with an anticholinergic agent.
In view of the noted side effects of anticholinergic agents, it would be preferable in some individuals to take advantage of the benefits of these drying agents without the requirement for persistent dosing around the clock. As noted, runny nose and/or constant clearing the throat may be considerably more intrusive during the daytime, social, or work hours for some individuals and control of these symptoms would be clearly more urgent than at night while sleeping.
It is a general pharmacotherapeutic principle to utilize medication as required to be effective and to avoid additional or unnecessary dosing to avoid side effects. The concept of dosing anticholinergic agents during the hours most needed, and not a times when it is less needed or not needed, is in accord with this concept. Limitation of dosing may be particularly helpful for individuals who are less tolerant of these agents, or of medication in general, yet are troubled with rhinorrhea or post nasal drip, or for individuals who are disposed to urinary/prostate or functional gastrointestinal disorders. In such individuals, dosing for the hours most needed and not at other times would be most suitable.
It is well known that individuals with rhinitis utilize rhinitis medications hundreds of millions of times a year. It is not uncommon for inappropriate choices to result in symptomatic worsening rather than improvement. There is a present need for preformulated regimens which advantageously use rhinitis medications in a manner to establish simplicity, reduce confusion, and increase convenience. While a number of rhinitis medications incorporate oral anticholinergic drying agents, no medication or medication regimen has been devised to instruct or otherwise alert a user to use anticholinergic agent during the waking hours and attenuate or not use such an agent during sleeping hours, such as to maximize therapeutic advantages and minimize side effects of such agents. Moreover, no such packaged regimen has been devised to make such treatments convenient and organized for a user.